What are the absolute and relative contraindications to oral prednisone?

Contraindications for Oral Prednisone

Oral prednisone has only two absolute contraindications: systemic fungal infections and known hypersensitivity to prednisone or its components. 1 All other contraindications are relative and require careful risk-benefit assessment based on the severity of the underlying condition being treated.

Absolute Contraindications

• Systemic fungal infections: Prednisone is absolutely contraindicated in the presence of active systemic fungal infections, as corticosteroids exacerbate these infections and should be avoided unless needed to control drug reactions. 1
• Known hypersensitivity: Documented allergy to prednisone or its components is an absolute contraindication, though true immediate hypersensitivity reactions to corticosteroids are rare (anaphylaxis occurs in 60.8% of reported allergic cases, with methylprednisolone being most commonly implicated). 1, 2

Relative Contraindications Requiring Careful Assessment

Infectious Disease Considerations

• Latent or active tuberculosis: Prednisone can reactivate tuberculosis in patients with latent infection or tuberculin reactivity; close monitoring and chemoprophylaxis are required during prolonged therapy. 1
• Hepatitis B carriers: Hepatitis B virus reactivation can occur with immunosuppressive doses of prednisone; screen patients before initiating prolonged treatment and consider antiviral prophylaxis in consultation with hepatology. 1
• Varicella or measles exposure in non-immune patients: These infections can have serious or fatal courses in corticosteroid-treated patients; prophylaxis with varicella zoster immune globulin or immunoglobulin may be indicated after exposure. 1
• Amebiasis: Corticosteroids may activate latent amebiasis, requiring caution in endemic areas or patients with prior infection. 1
• Acute local infections: Do not administer prednisone by intra-articular, intrabursal, or intralesional routes in the presence of acute local infection. 1

Metabolic and Endocrine Conditions

• Uncontrolled diabetes mellitus: Prednisone induces glucose intolerance and hyperglycemia; careful evaluation and glucose monitoring are essential before initiating therapy, particularly at doses >7.5 mg/day. 3
• Hypothyroidism or hyperthyroidism: Metabolic clearance of prednisone is decreased in hypothyroid patients and increased in hyperthyroid patients, necessitating dose adjustments. 1

Cardiovascular Conditions

• Uncontrolled hypertension: Prednisone can cause salt and water retention and elevate blood pressure; cautious use with close monitoring is required. 3, 1
• Severe cardiovascular disease: Long-term use at doses ≥7.5 mg/day increases cardiovascular risk including coronary artery disease and atrial fibrillation; risk-benefit assessment is critical. 3
• Recent myocardial infarction: Literature reports suggest an association between corticosteroid use and left ventricular free wall rupture after recent MI; use with great caution in this setting. 1

Gastrointestinal Conditions

• Active peptic ulcer disease: While the absolute risk of peptic ulcer is relatively low (0.4% vs 0.3% placebo), active peptic ulcer disease is a relative contraindication requiring consideration of alternative treatments or gastroprotection. 3

Psychiatric and Neurological Conditions

• Severe psychiatric disorders: Prednisone can cause psychosis, mood disturbances, and emotional instability; patients with severe behavioral symptoms or psychiatric disorders require careful evaluation and close monitoring during therapy. 3

Musculoskeletal Conditions

• Severe osteoporosis: Long-term prednisone therapy increases fracture risk; patients with severe osteoporosis require careful consideration of alternatives, bone protective measures (calcium 1,200-1,500 mg/day, vitamin D 800-1,000 IU/day), and bisphosphonate therapy for men ≥50 years on doses ≥5-7.5 mg/day. 3, 4

Critical Decision-Making Framework

When relative contraindications are present, the decision to use prednisone depends on whether the underlying condition is life-threatening or organ-threatening. 5

• For life- or organ-threatening disease (e.g., severe autoimmune conditions, acute respiratory distress syndrome), the benefits of prednisone likely outweigh the risks even with relative contraindications present. 5
• For non-life-threatening conditions with absolute or multiple severe relative contraindications, consider alternative immunosuppressive agents such as cyclophosphamide, calcineurin inhibitors, or biologic agents. 3
• Use the lowest effective dose to control disease, particularly when relative contraindications exist. 5

Common Pitfalls to Avoid

• Abrupt withdrawal: Patients receiving >7.5 mg/day for >3 weeks are at risk for adrenal suppression; avoid abrupt discontinuation and consider stress dosing during illness or surgery. 5, 1
• Ignoring infection risk: The rate of infectious complications increases with increasing corticosteroid dosages; monitor closely for new infections and consider dose reduction or withdrawal if serious infection develops. 1
• Failure to screen for latent infections: Screen for tuberculosis and hepatitis B before initiating prolonged immunosuppressive therapy. 1
• Inadequate bone protection: Initiate calcium and vitamin D supplementation immediately for patients anticipated to receive ≥5-7.5 mg/day long-term. 4